RA 


UC-NRLF 


B    3    bS3    7bfl 


September,  1916 


RELATIVE   VALUES  IN   PUBLIC 
HEALTH   WORK 


BY 

FRANZ  SCHNEIDER.  JR. 

SANITARIAN 

DEPARTMENT   OF   SURVEYS   AND   EXHIBITS 
RUSSELL  SAGE   FOUNDATION 


READ  BEl  ^RE  THE  MASSACHUSETTS  ASSOCIATION  OF   BOARDS  OF  HEALTH. 

PROVlOtNCE.  R.  I..  JULY  27.  1916.    REPRINTED  FROM  AMERICAN  JOURNAL 

OF  PUBUC  HEALTH.  VOL.  VI,  NO.  9.  SEPTEMBER,  1916 


Department  of  Surveys  an'd  Exhibits 

Russell  Sage  Foundation 
130  East  Twentv'-second  Street,  New  York  City 


Price  10  C.   t» 


XS^i^ 


3^ 


RELATIVE  VALUES  IN  PUBLIC  HEALTH  WORK. 

Franz  Schneider,  Jr., 
Department  of  Surveys  and  Exhibits,  Russell  Sage  Foundation,  New  York  City. 


ABOUT  1,400,000  persons  die  in 
continental  United  States  each 
year.  Probably  a  fourth  or 
a  third  of  these  die  from  preventable 
causes.  In  addition,  it  is  asserted, 
and  recent  sickness  surveys  seem  to 
support  the  claim,  that  two  or  three 
per  cent.  6i  our  population  are,  at  any 
one  time,  disabled  through  sickness. 
Then  there  is  the  larger  number  of 
persons  afflicted  with  illnesses  not 
serious  enough  to  disable  but  which 
cause  loss  of  comfort  and  efficiency. 

The  task  of  preventing  these  vast 
amounts  of  sickness  and  death,  so  far 
as  is  possible,  is  delegated  by  the  public 
to  its  health  authorities.  The  latter 
nuist  decide  what  parts  of  the  losses 
are  preventable,  and  must  determine 
how  the  greatest  return  in  prevention 
can  Ik?  obtained  with  the  money  avail- 
able. This  is  the  problem  of  relative 
values  in  j)ublic  health  work. 

If  unlimited  funds  were  at  the  dis- 
posal of  health  depa.  ments  the  prob- 
lem of  relative  values  would  be  one  of 
merely  theoretical  interest.  The  ad- 
ministrator would  need  only  to  insti- 
tute all  the  activities  that  seemed 
likely  to  e.xert  a  beneficial  effect,  and 
at  the  close  of  the  year  prepare  a  table 
of  expenditures  with  regard  to  the 
several  activities.  This  list  would 
indicate  the  relative  value  attached  to 
different   activities  when  no  stone   is 


left  unturned,  but  would  be  a  tabula- 
tion of  purely  academic  interest. 

Quite  different  is  the  situation  actu- 
ally confronting  health  officials.  With 
the  scanty  funds  now  at  their  disposal, 
and  the  great  variation  in  effectiveness 
of  different  activities,  the  most  careful 
discrimination  must  be  exercised  in 
making  up  the  department's  program. 
A  bad  distribution  of  funds  means 
lives  lost,  and  the  responsibility,  a 
heavy  one,  falls  on  the  administrative 
official.  The  problem  is  rendered  the 
more  difficult  by  the  lack  of  accurate 
data  as  to  costs  and  results.  The 
practical  importance  of  an  accurate 
appreciation  of  relative  values  can 
hardly  be  overemphasized.  Professor 
Whipple,  in  discussing  the  subject 
says,  "This  is  one  of  the  greatest  ques- 
tions that  a  sanitarian  can  consider. 
It  is  today  the  most  important  of  all 
hygienic  problems  because  it  compre- 
hends all  others."* 

The  Field  of  Prevention. 

In  attempting  to  determine  values 
it  seems  reasonable  to  take  vital  statis- 
tics as  the  point  of  departure.  Our 
death  and  sickness  records  suggest  the 
opportunities  that  lie  before  us,  and  it 
is  by  these  figures  that  we  must  judge 
the   efficacy   of   our   endeavors.     Our 


♦Whipple,    G.    C:    "How   to   Determine   Relative 
Values  in  Sanitation";  American  City,  X,  5,  p.  427. 


.•Uel4iiv.e.t^a1iio.s  in   rul)lic  Health  Work 

TABLE   1. 
PREVENTABLE   DEATHS  IN  ALL   REGLSTRATION  CITIES,   1913. 


Cause  of  death. 


Number  of  deaths. 


Per  cent,  of  pre- 
ventable <leaths. 


Infectious  Di.seases 

Tuberculosis — all  forms: 

Lmigs        

Meiiiniiptis 

Other  forms 

Diarrhea  and  enteritis  (under  i) 

Bronchopneumonia 

Common  contagious  diseases 

Measles 

Scarlet  fever 

Whoopinp-cough 

Diphtheria  and  croup 

Typhoid  fever 

SjTJhilis — total 

Syphilis 

Locomotor  ataxia 

Softening  of  the  brain 

Influenza 

Puerperal  fever 

Gonococcus  infection 

Other  infectious  diseases 

Erysipelas 

Dysentery 

Tetanus 

Cereljrospinal  fever 

Malaria 

Infantile  paralysis 

(  Iiolera  nostras 

"Otlier  epidemic  diseases" 

Rabies.  .  ." 

Smallpox 

Intestinal  parasites 

Mycoces 

Hyatid  tumor  of  liver 

Anthrax 

Ankylostomiasis 

(ilanders ... 

Ix"i)rosy 

Typhus  fever 

Relapsing  fever 

Plague 

Nutritional  Diseases 

Pellagra 

Rickets 

Scurvy 

Beriberi 

Poisoning  by  Food 

Industrial  Poisonings 

Lead  poisoning 

Other  chronic  occupational  poisonings. 

Total — preventable  deaths 


48,733 
3,8G1 
4,030 


1,599 

1,4H 

876 

834 

644 

39:2 

140 

124 

67 

44 

30 

24 

13 

12 

10 

7 

4 

3 

2 

1 

702 

335 

53 

7 


120 
4 


149,600 
56,624 


30,244 
21,091 
19,058 


5,627 
4,902 


3,000 

2,825 

191 

6,038 


1,097 


329 
124 


151,150 


99  0 
37  5 


20.0 
14.0 
12.6 


3.2 


2.0 
1.9 
0.1 
4.0 


0.7 


0.2 
0.1 


100.00 


Relative  Values  in  Public  Health  Work 


sickness  records  are,  unfortunately, 
so  fragmentary  as  to  be  of  little  prac- 
tical value,  while  our  death  records 
are  reliable  for  only  two  thirds  of  the 
country.  Let  us  turn,  however,  to 
the  mortality  statistics  for  1913,  and 
seek  to  discover  the  opportunities  for 
prevention. 

The  registration  cities  of  the  country 
represented  in  1913  a  population  of 
34,230,583,  or  35  per  cent,  of  the  total. 
In  Table  1  an  attempt  is  made  to  show 
the  preventable  deaths  occurring  in 
these  cities.  This  table  is  intended 
to  include  all  infectious  diseases;  cer- 
tain nutritional  diseases,  such  as  beri- 
beri and  pellagra;  industrial  poisonings; 
and  food  poisonings.  Certain  of  the 
infectious  diseases  included,  such  as 
puerperal  fever,  will  seem  novel  in 
connection  with,  health  department 
activities.  They  are  included  on  the 
theory  that  being  infectious,  they  are 
preventable;  that  ultimately  we  may 
come  to  prevent  them;  and  that  the 
health  department  is  the  only  govern- 
mental agency  whose  business  it  is  to 
prevent  them.  The  numbers  of  deaths 
from  these  diseases  are,  furthermore, 
relatively  small. 

There  are  conspicuous  omissions 
from  the  list.  Cancer  is  a  striking 
example.  No  one  doubts  that  many 
deaths  from  cancer  may  be  avoided 
through  early  operation,  and  allowance 
must  be  made  for  this  disease  in  making 
up  relative  values;  however,  it  has 
seemed  better  to  omit  cancer  from  this 
list,  and  to  lump  it  in  with  the  degener- 
ative diseases  of  middle  age.  Allow- 
ance will  be  made  for  this  group  of 
diseases  under  the  heading  of  health 
education.     Again,  the  list  disregards 


the  great  group,  Diseases  of  Early 
Infancy,  from  which  something  cer- 
tainly can  be  saved.  In  addition, 
bronchopneumonia  is  included  entire 
and  placed  in  the  infant  group,  while 
all  other  forms  of  pneumonia  are 
omitted.  Finally,  the  list  seriously 
understates  the  losses  caused  by  the 
venereal  diseases,  making  no  effort 
to  include  the  deaths  that  may  be  due 
to  syphilis  but  that  are  registered 
under  diseases  of  the  arteries  and  other 
organs,  although  it  does  include  deaths 
from  locomotor  ataxia  and  softening 
of  the  brain.  The  list  also  disregards 
deaths  from  such  causes  as  salpingitis — 
deaths  in  which  gonorrhea  may  play 
a  part.  An  attempt  to  make  due 
allowance  for  these  inclusions  and 
omissions  will  be  made  later  in  the 
paper. 

It  is  worthy  of  note  that  this  list 
of  preventable  deaths,  although  con- 
servative, totals  151,150,  or  29  per 
cent,  of  the  deaths  from  all  causes. 

Damage  Done  as  a  Criterion. 

When  we  come  to  compare  the 
different  diseases  in  the  list  it  becomes 
evident  that  relative  importance  can- 
not be  tested  adequately  by  any 
single  criterion,  but  that  several  of 
fairly  eciual  importance  must  be  con- 
sidered. One  of  the  most  obvious 
tests  is  the  number  of  deaths  caused 
by  each  disease.  On  this  basis  tuber- 
culosis, responsible  for  56,624,  or  37.5 
per  cent,  of  the  whole  preventable  list, 
is  the  most  important.  Second  in 
importance  comes  diarrhea  and  en- 
teritis among  children  under  two, 
resj)onsible  for  30,244,  or  20.0  per  cent. 
Next  comes  bronchopneumonia,  with 


.S89219 


Kehitive  Values  in   Public  Health   Work 


14.0  per  cent.;  followed  closely  by  the 
four  common  contapous  diseases  of 
children— dij)litlieria,  scarlet  fever, 
whooi)ing-cou<.'h,  and  measles,  respon- 
sible as  a  group  for  li2.0  j)er  cent,  of 
the  deaths. 

But  the  number  of  deaths  is  not 
an  adeciuate  measure  of  the  damage 
done.  For  one  thing,  it  fails  to  take 
account  of  non-fatal  illness.  Perhaps 
the  extreme  example  of  this  failure 
is  gonorrhea.  In  the  table  this  disease 
is  rejjresented  l)y  only  191  deaths, 
about  0.1  of  one  per  cent,  of  the  total; 
yet  we  know  that  gonorrhea  is  one  of 
the  commonest  of  communicable  dis- 
eases, and  that  its  public  health  im- 
portance is  far  in  excess  of  the  figure 
just  given.  Other  examples  of  diseases 
with  low  fatality  rales,  and  whose 
importance  is  inadequately  represented 
by  the  death  test  are  hookworm  and 
malaria.  In  measuring  the  loss  due 
to  any  preventable  disease  we  must 
consider  not  only  the  number  of  deaths 
but  the  number  of  cases  of  non-fatal 
sickness,  the  duration  of  attack,  and 
the  seriousness  of  secondary  effects 
or  imj)airments.  Unfortunately,  our 
knowledge  of  these  things  is  imperfect. 

Another  factor  c-omes  into  the  esti- 
mate of  damage  done — the  relative 
value  of  the  lives  lost  or  temporarily 
disabled.  The  econolnic  value  of  an 
infant  is  of  course  not  as  great  as  that 
of  a  wage-earner.  On  the  other  hand, 
we  realize  that  economic  value  is  an 
unsatisfactory  measure  of  the  value 
of  life,  and  is  one  the  public  is  inclined 
not  to  accept.  Afost  of  us  would  put 
the  humanitarian  side — the  anguish 
caused  those  near  and  dear — abo\-e 
economic  value;  and  on  this  basis  the 


loss  of  an  infant  may  be  as  important 
as  that  of  an  older  person.  The  argu- 
ment that  the  loss  of  a  wage-earner 
nuiy  have  a  serious  effect  on  a  greater 
number  of  persons  is  one  deserving 
more  consideration. 

Preventability  as  a  Criterion. 

Passing  from  damage  done,we  come 
to  another  criterion  of  the  first  im- 
portance— preventability.  Certain  of 
our  "preventable"  diseases  are  much 
more  preventable  than  others.  Small- 
pox is,  by  vaccination,  almost  abso- 
lutely preventable.  Typhoid  fever  is 
another  disease  we  are  prepared  to 
attack  with  great  confidence  if  the 
necessary  funds  and  powers  are  at  our 
disposal.  Infantile  paralysis,  on  the 
other  hand,  is  much  more  difficult  to 
curb;  and  measles,  with  its  period  of 
infecti\ity  principally  before  the  ap- 
pearance of  symptoms,  is  largely  in- 
dependent of  our  efforts.  Similarly, 
we  expect  quicker  and  more  sharply 
defined  results  from  infant  hygiene 
work  than  from  that  directed  against 
tuberculosis. 

Attention  must  be  given  not  only 
to  the  general  preventability  of  the 
disease,  but  to  the  degree  of  prevalence. 
It  is  generally  easier  to  secure  results 
in  a  virgin  field.  After  a  death-rate 
has  been  forced  down  to  a  certain 
level,  each  new  unit  of  reduction  is 
successivelj'  more  difficult.  This  is 
the  problem  of  residuals,  and  must  be 
considered  with  reference  to  local 
conditions. 

Cost  of  Prevention  as  a  Criterion. 

A   third  major  criterion  is  cost  of 

prevention.     The  great  importance  of 

this  factor  is  enforced  by  the  meagre- 


Relative  Values  in  Public  Health  Work 


ness  of  the  funds  at  our  disposal.  In 
some  respects  cost  is  the  most  im- 
portant criterion  of  all.  It  can  be 
arjiued  that  in  considering  activities 
we  should  determine  what  line  of  effort 
will  save  a  unit  of  life  or  health  for  the 
least  money,  and  then  prosecute  that 
activity  alone  until  the  law  of  diminish- 
ing return  brings  the  activity  to  a  par 
with  its  nearest  rival. 

Such  a  one-sided  program  is  of  course 
impracticable.  Even  if  theoreticallj^ 
desirable,  which  is  questionable,  such  a 
course  would  not  be  tolerated  by  public 
opinion.  Great  weight  must,  however, 
be  given  to  the  factor  of  cost.  The 
figure  used  should  include  only  that 
to  the  health  department,  and  not 
that  to  society  as  a  whole.  Otherwise 
we  shall  become  entangled  in  questions 
of  other  standards  of  value,  such  as 
comfort,  convenience,  and  aesthetics; 
and  these  seem  to  be  matters  to  be 
interpreted  by  the  demographer,  and 
evaluated  by  the  people  themselves. 

COMMUNICABILITY   AS   A    CRITERION. 

Another  factor  that  seems  to  de- 
serve consideration  is  the  communica- 
bility  or  contagiousness  of  a  disease; 
in  other  words,  its  tendency  to  become 
epidemic.  On  account  of  this  prop- 
erty, certain  diseases,  such  as  smallpox, 
must  be  suppressed  immediately  upon 
appearance,  almost  without  regard  to 
cost  and,  it  may  be,  quite  without  re- 
gard to  the  amount  of  damage  they 
may  have  done  in  the  community 
during  the  last  year,  or  the  last  ten 
years.  Such  diseases,  if  neglected, 
may  quickly  cause  extremely  abnormal 
damage.     Communicability      appears 


not  to  be  correlated  with  the  other 
three  factors.  Infant  mortality,  for 
example,  which  receives  high  ratings 
with  regard  to  damage  done,  preventa- 
bility,  and  cost,  receives  a  relatively 
low  rating  for  communicability.  Ac- 
cordingly this  factor  seems  to  qualify 
as  a  separate  criterion. 

Solution  for  Relative  Values. 

in  general,  then,  the  relative  value 
of  a  disease,  or  of  an  activity  to  pre- 
vent a  disease  or  diseases,  would  seem 
to  depend  on  four  prime  factors:  first, 
amount  of  damage  done;  second,  pre- 
ventability;  third,  cost  of  prevention; 
fourth,  tendency  to  become  epidemic. 
As  a  formula  this  might  be  expressed: 

Value  =  Damage  X  Preventability  X 
Cost  X  Communicability. 

Certainly  these  seem  to  be  the  main 
criteria.  Perhaps  weights  should  be 
assigned  to  the  four  factors,  but  thi^  is 
a  refinement  one  hesitates  to  attempt. 
It  should  be  noted  that  in  the  for- 
mula, cost  is  in  the  nature  of  an  inverse 
factor. 

One  other  point  deserves  attention. 
Certain  activities  are  indispensable  to 
a  health  department.  For  example, 
nothing  is  more  important  than  the 
registration  of  vital  statistics,  yet  it 
is  obviously  difficult  to  assign  any 
number  of  deaths  prevented  by  this 
work.  Similarly  it  is  difficult  to 
measure  the  results  of  health  educa- 
tion, although  we  feel  sure  it  is  an 
important  part  of  the  program.  Per- 
haps activities  of  this  kind  should  be 
regarded  as  in  the  nature  of  "over- 
head" charges.  At  all  events,  they 
should  be  assigned  a  liberal  value. 


Relative  Values  in  Public  Health  Work 


Relatht:  Value  of  Different 
Causes  of  Death. 

The  task  of  applying  these  criteria 
and  of  deri\ing  a  set  of  values  is  a 
difficult  one.  In  ofTcring  the  following 
values  no  claim  is  made  for  a  high 
degree  of  accuracy.  It  is  believed, 
however,  that  tlie  values  derived  per- 
mit a  considorahle  margin  for  difference 
of  opinion  without  altering  the  gene^^ 
conclusions  which  the  figures  suggest. 
The  method  may,  moreover,  suggest 
ways  in  which  more  accurate  values 
eventually  will  be  derived.  The  cal- 
culations involved  appear  in  Tables  2 
and  3. 

Starting  with  tlie  original  hst  of 
preventable  deaths  (Table  1),  an 
estimate  has  been  made  of  the  damage 
done  by  the  different  causes.  This 
estimate  is  intended  to  give  due  weight 
to    non-fatal    illness,    and    the    other 


damage  factors  already  mentioned. 
The  proportions  of  damage  done  as- 
signed to  the  diseases  are,  arranged  in 
order  of  magnitude,  as  follows:  tuber- 
culosis, 25  per  cent.;  infants'  diseases, 
25  per  cent.;  venereal  diseases,  20  per 
cent.;  the  four  common  contagious 
diseases  of  children,  15  per  cent.; 
typhoid  fever,  5  per  cent.;  other  in- 
fectious diseases,  8  per  cent.;  nutri- 
tional diseases,  1  per  cent. ;  and  poison- 
ing by  food,  1  per  cent. 

These  values  have  been  multiplied 
by  what  seem  appropriate  factors  rep- 
resenting preventability,  cost  of  pre- 
vention, and  tendency  to  become 
epidemic,  the  various  steps  of  the 
computation  appearing  in  Table  2. 
The  resulting  values,  which  relate  to 
causes  of  death  and  not  to  lines  of 
activity  are,  when  reduced  to  per  cents 
and  arranged  in  order  of  magnitude, 
as  follows. 


TABLE  2. 

CALCULATION  OF  VALUES  FOR  DIFFERENT  CAUSES  OF  PREVENTABLE  DEATH— AND  ADJUSTMENT  TO 
INCLUDE  VALUES  ARBITRARILY  ASSIGNED.* 


I. 

II. 

III. 

IV. 

V. 

VI. 

VII. 

VIII. 

IX. 

X. 

XI. 

Cause  of  death. 

Per 

cent. 

of 

deaths. 

Estimate 

of 

damage 

done. 

Factor«> 

for 
preventa- 
bility. 

II 

times 
III. 

Factor 

for 
cost." 

rv 

times 
V. 

Per 
cent. 

Factor 

for 

communi- 

cability. 

VI 
times 
VIII. 

Per 

cent. 

X 

times 
0.73. 

Ttiborculosis 

37.5 

34.0 

(20  0) 

(14.0) 

12.0 

3  3 

3.7 

7  9 

0  7 

0  2 

0.1 

25.0 
25.0 

15  0 
20  0 
5  0 
8.0 
1.0 
10 

d 

6 
8 

6 
5 

g 

5 
6 

1 
d 

150 
200 

90 
100 
45 
40 

6 

1 
d 

4 
10 

6 
4 
8 
5 
6 
1 

600 
2,000 

540 
400 
360 
200 
30 
1 

14.5 
48.4 

13.1 
9.7 
8.7 
4.9 
0.7 
0.0 

5 
3 

10 
4 
3 
3 

3.000 
6,000 

5,400 

1,600 

1,080 

600 

•30 

•1 

16.9 
33.9 

30.5 
9.0 
6.1 
3.4 
0.2 
0.0 

12.3 

24.7 

Dinrrhra  and  enteritis 

Bronchopneumonia 

Conta«ioii!<ilis<>aac8  of  children. . 

22.3 
6.6 

Tv|)hoii|  fever 

4.5 

Other  infectious  diseaaea 

2.5 
0.1 

0.0 

Iniluatrial  poisonings 

ToUl 

100  0 

100  0 

4,131 

100.0 

17,711 

100.0 

73.0 

*  BasrtI  on  mortality  in  all  retcistrations  cities,  1913. 

*<  Fartors  on  a  scale  of  10;  that  number  being  most  favorable  rating,  one  being  the 
least  favorable. 

*  Cost — to  health  department. 
"*  Disregarded. 

*  Factor  for  communicability  not  applied  in  these  cases. 


Values  arbitrarily  assigned: 

Inspection  of  school  children 7.0 

Education 5.0 

Vital  statistics. 5.0 

Dispensar;,'  and  clinics 5.0 

Laboratory 5.0 

ToUl 100.0 


Relative  Values  in  Public  Health  Work 


First:  infants'  diseases,  33.9  per 
cent.  The  two  causes  included  under 
this  heading,  diarrhea  and  enteritis 
under  two  and  bronchopneumonia,  are 
responsible  for  34  per  cent,  of  the 
deaths  in  the  preventable  list.  Bron- 
chopneumonia, responsible  for  14  per 
cent.,  includes  deaths  of  other  than 
infants;  but  the  median  age  of  the 
deceased  is  1 .5  years,  and  68  per  cent, 
of  the  deaths  occur  among  children 
under  five.  To  compensate  for  the 
deaths  improperly  included,  there  are 
the  deaths  of  infants  from  several 
other  causes  which  I  have  disregarded, 
— such  causes  as  pneumonia,  and  the 
group  Diseases  of  Early  Infancy. 
Deaths  of  infants  under  two  amount  to 
over  one  fifth  of  all  the  deaths  that 
occur,  and  in  our  list  of  preventable 
deaths  this  group  of  infants  accounts 
for  over  a  third  of  the  total.  In  an 
unworked  field,  infant  mortality  offers 
a  high  degree  of  preventability  at  a 
low  cost ;  if  it  were  not  for  a  low  rating 
on  communicability  it  would  attain 
even  a  higher  value  than  it  does. 

Second :  the  four  contagious  diseases 
of  children,  30.5  per  cent.  These 
diseases  are  responsible  for  13  per  cent, 
of  the  preventable  deaths,  and  are 
estimated  to  be  responsible  for  15  per 
cent,  of  the  damage  done.  They  are 
the  most  likely  to  become  epidemic, 
a  fact  that  contributes  largely  to  their 
high  final  rating. 

Third:  tuberculosis,  16.0  per  cent. 
Although  responsi})le  for  37.5  per  cent, 
of  the  |)reventablc  deaths,  its  value 
is  reduced  l)y  high  cost  of  prevention, 
moderate  preventability,  and  absence 
of    the    acute    tendency    to    become 


epidemic  that  characterizes  some  of 
the  other  communicable  diseases. 

The  fourth  value  falls  to  the  venereal 
diseases,  9  per  cent.  Although  only 
3.3  per  cent,  of  the  preventable  deaths 
can  be  definitely  ascribed  to  these 
diseases  it  is  certain  that  they  cause 
many  deaths  that  are  registered  under 
other  titles.  In  addition,  there  is  a 
tremendous  number  of  non-fatal  cases, 
and  the  indirect  results  of  these  are 
frequently  grave.  Conservative  esti- 
mates have  placed  the  number  of  cases 
in  the  country  at  tAvo  or  three  million. 
This  field  is  almost  untouched,  and 
health  department  effort  in  the  way  of 
education,  diagnosis,  and  treatment, 
should  accomplish  great  good. 

The  fifth  place  goes  to  typhoid  fever, 
with  a  value  of  6.1  per  cent.  Then 
follow  other  infectious  diseases,  3.4 
per  cent.;  and  nutritional  diseases,  0.2 
per  cent.  Poisoning  by  food  registers 
less  than  0.1  per  cent. 

These  are  values  calculated  for  the 
different  causes  in  our  list  of  prevent- 
able deaths.  It  is  necessary  now  to 
make  allowance  for  certain  diseases, 
such  as  cancer  and  the  degenerative 
diseases  of  middle  age,  which  were  not 
included  in  that  list;  to  make  allowance 
for  certain  activities  that  are  indisj)en- 
sable  to  a  health  department;  and  to 
express  the  result  in  terms  of  health 
department  organization. 

Values  According  to  Lines 
OF  Activity. 

To  health  education  an  arbitrary 
value  of  5  per  cent,  in  the  final  scale  is 
assigned.  This  item  will  cover  activi- 
ties in  behalf  of  the  semi-preventable 
diseases  just  mentioned.     Similarly,  a 


Uelatiw  Values  in    Piihlic-  Ilealtli  Work 


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of  7  is  assigned  to  the  physical 
nation  of  school  chiUiron,  and  a 
of  ')  to  each  of  the  foHowiiif^  ac- 
s:     \if;il     statistics,     dispensary 


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and  clinics,  and  laboratory.  As  these 
arbitrarily  assigned  items  aggregate  '27 
per  cent.,  it  is  necessary  to  reduce 
propcjrtionally  the  previously  deter- 
mined disease  values  to  make  them 
total  73  per  cent.  Table  3  exhibits 
the  distribution  of  what  seem  ap- 
propriate parts  of  these  reduced 
values  among  the  following  activ- 
ities: milk  control,  privy  and  well 
sanitation,  fly  and  mosquito  suppres- 
sion, and  food  sanitation.  The  result 
is  the  following  hst  of  final  values, 
expressed  according  to  lines  of  health 
department  activity. 

TABLE  4. 

Final  valiios*  as  applied  to  actiWlies  directly 
concerned  with: 

Control  of  Communicable  Diseases — 

Tui)erculosis HI 

Ve  iiereai  diseases G .  6 

All  others i5  S 

Infant  hypiene iO  S 

I'riv\  and  well  sanitation 3  .5 

Milk  control 4.7 

I'ly  and  mosquito  suppression •i  A 

Food  sanitation 0  1 

Inspection  of  school  children 7.0 

Vital  statistics 5  0 

Education 5  0 

Dispensary  and  clinics 5.0 

Laboratory 5.0 

Total 100.0 

*  For   a   more   detailed   sutniivision    of   values   see, 
Chapin,  C.  V.:  "Effective  Lines  of  Healtti  Work,"  The 
Providence  Medical  Journal,  Januarj-,    1916.     Persons 
■"sted  in  relative  values  should  consult  also,  "How 
^.  ..-  "^ijend   the  Health   Appropriation,"   by   the 

same  auth<v,  -American  Journ.^l  of  Public  He.m.th, 
Vol   III,  No.  3,  page  202. 

The  A  alue  '2.).3  for  communicable 
di.sea.ses  other  than  tuberculosis  and 
the  venereal  di.seases  may  .seem  high  as 
compared  with  the  values  for  those 
specific  di.sea.ses  and  that  for  infant 
hygiene.  On  the  other  hand,  this 
25.3  per  cent,  must  cover  the  work 
against    the    common    contagions    of 


Relative  Values  in  Public  Health  Work 


9 


children,  as  well  as  that  against  ty- 
phoid fever,  smallpox,  and  others  of 
the  more  unusual  diseases.  It  must 
take  care  also  of  the  possibilities  in 
connection  with  pneumonia.  In  addi- 
tion, infant  hygiene  is  represented  by 
4.5  per  cent,  in  the  allowances  for  milk 
control,  privy  and  well  sanitation,  and 
fly  suppression.  It  is  assumed  that 
control  of  communicable  diseases  will 
be  carried  on  with  modern  epidemiolog- 
ical methods,  public  health  nurses,  and 
emphasis  on  bedside  disinfection  of 
discharges. 

The  list  of  final  values  does  not  con- 
sider industrial  hygiene;  not  because 
the  work  is  unimportant,  but  on  the 
theory  that  state  authorities  will  meet 
the  need.  Plumbing  inspection  does 
not  appear,  partly  because  of  lack  of 
evidence  to  justify  its  insertion,  and 
partly  because  this  is  considered  work 
for  the  building  department.  Nuisance 
abatement  is  intentionally  omitted; 
it  is  realized,  however,  that  health 
departments  commonly  must  carry 
this  largely  police  function.  The  privy, 
well,  fly,  and  mosquito  work,  for 
which  allowance  has  been  made,  cover 
the  important  sanitary  parts  of  what 
is  generally  understood  by  nuisance 
abatement.* 

Before  leaving  these  values  it  seems 
wise  to  utter  a  few  words  of  warning. 
The  values  are  based  on  the  rates  of 
mortality  existing  in  registration  cities 


♦  For  a  vigorous  exposition  of  existine  inconsistencies 
see,  Armstrong.  D.  B.,  "Public  Health  Values— A 
Few  Modern  Fallacies,"  Proc<-eding9  of  the  Fifth 
Annual  Conference  of  Mayors  of  New  York  State: 
25  Washington  Ave.,  Albany,  1914.  For  an  excellent 
critical  discussion  of  the  relative  value  of  different 
branches  of  his  own  work  by  a  practi.sing  health  officer 
see,  Terry,  C.  E  ,  .Annual  Keport  of  the  Board  of  Health 
for  1915,  Jacksonville,  Fla.,  page  47. 


as  a  whole  in  1913,  and  thus  represent 
certain  average  conditions.  Local  con- 
ditions will  of  course  modify  any 
values,  as  will  the  passage  of  time  and 
the  development  of  sanitary  science. 
Similarly,  the  importance  of  different 
health  measures  in  any  one  city  will  be 
different  at  different  times.  It  must 
be  confessed  that  the  existing  data  for 
the  determination  of  relative  values  is 
seriously  inadequate.  What  we  need 
for  better  values  is  better  vital  statis- 
tics and  better  cost-keeping.  Probably 
nothing  would  be  a  greater  help  to  the 
progress  of  this  subject,  and  perhaps  of 
sanitary  science  in  general,  than  for 
our  health  officers  to  form  the  habit 
of  keeping  careful  records  regarding 
new  procedures,  together  with  state- 
ments of  the  results  and  the  costs. 
These  could  be  published  in  the  de- 
partments' annual  reports;  and  thus 
there  would  be  accumulated  a  mass  of 
data  comparable  to  that  in  the  hand- 
books now  existing  in  the  fields  of  civil 
and  mechanical  engineering. 

Some  health  officers,  of  course,  do 
this  already;  none  more  admirably 
than  Doctor  Chapin  of  Providence. 
On  this  occasion  one  is  tempted  to  ex- 
press one's  admiration  of  Doctor 
Chapin's  reports  and  other  writings, 
and  say  what  models  of  scientific  work 
they  are,  and  say  how  much  we  all  owe 
to  him.  But  one  hesitates  to  do  so, 
from  fear  that  he  would  dislike  it.  At 
all  events,  when  we  ha^•e  more  reports 
like  Doctor  Chapin's  we  shall  be  in  a 
fair  way  to  get  our  judgments  of 
relative  values  onto  a  definite  quan- 
titative basis. 

Making  liberal  allowance  for  in- 
accuracies in  the  values  here  presented. 


10 


Relative  Values  in  Public  Health  Work 


and  for  possible  diflVrenres  that  may 
1)0  occasioned  hy  local  conditions,  the 
followiiifi  conclusions  seem  fully  justi- 
fied: 'I'he  prevention  of  infant  mortal- 
ity is  a  fundamental  activity,  and  one 
of  the  most  valuahle  a  health  depart- 
ment can  pursue.  \'ery  exceptional 
is  the  city  in  which  this  work  can  he 
iji;nored  without  convicting  the  health 
authorities    of    gross    neglect.     Anti- 


tuberculosis work  and  that  involved 
in  the  control  of  the  common  conta- 
gious diseases,  are  other  activities  of 
I)rime  importance.  In  addition,  it 
seems  time  to  admit  the  venereal 
(lisea.ses  to  the  group  of  larger  oppor- 
tunities. In  most  cities  the  value  of 
the  al)ove  mentioned  lines  of  activity 
is  considerably  greater  than  that  of  the 
various  forms  of  sanitary  inspection. 


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